Karen Taylor

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National Audit Office Value for Money
StudyPlace of End of Life Care

• Karen Taylor
• 2nd December 2008

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What does the National Audit Office do?

• Scrutinise the economy, efficiency and
  effectiveness of public spending.
• Totally independent of Government and headed by
  the Comptroller and Auditor General, who is an
  Officer of Parliament.
• Audit the accounts of all Central Government
  bodies
• AND produce around 60 value-for-money reports
  each year (7 on health issues)
• Work closely with the Parliamentary Committee of
  Public Accounts (PAC), whose hearings and
  investigations are based on our work.
• Save the taxpayer 9 for every 1 it costs to run
  the NAO (savings of 582 million in 2006-07)

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Study of End of Life Care

• Chairman of PAC requested study in 2005. NHS End
  of Life Care Programme ongoing at the time
  therefore study deferred until 2008
• In intervening time Mike Richards remit extended
  to End of Life Care
• Report Published 26th November
• Parliamentary hearing 17th December

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Study of End of Life Care

• Study examined
• Whether effective EOLC is being commissioned and
  provided in appropriate settings and the extent
  and costs of these services across England
• Equality and consistency of access
• Barriers that certain individuals face in
  accessing these services and
• Whether current provision of services is of good
  quality and respects patient choice and dignity

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End of Life Care
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Methodologies

• Census of PCTs
• Census of independent and NHS run hospices
• Survey of doctors and nurses
• Survey of care homes
• Focus groups of patients, current and bereaved
  carers
• Review of deceased patients records
• Economic modelling of costs and potential savings
• In-depth PCT case studies
• Use of existing data and research

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High Level Findings

• Some people receive high levels of care but many
  do not with many aspects of NHS and social
  care not meeting basic needs on dignity and
  respect.
• There is a gap between preferred and actual place
  of death (up to 74 prefer to die at home in
  reality 58 occurred in a hospital setting (
  range 46 77 across PCTs) also varies by age
  and condition cancer patients more likely to
  die at home or in a hospice.
• Proportion of patients with cancer expressing a
  preference for home care decreases as death
  approaches (from 90 to 50) replaced by a
  preference for hospice care (from 10 to 40) -
  94 of all hospice deaths are patients with
  cancer.
• A lack of prompt access to services in the
  community leads to people being unnecessarily
  admitted to hospital

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High Level Findings

• PCT data is limited, what they can provide shows
  wide variation e.g. specialist palliative care
  spend per death (154 to 1,684)
• PCTs contracts with hospices limit hospices
  ability to deliver services, and funding varies
  widely (provide on average 26 (130 million) of
  independent hospices expenditure also 70 have
  only annual contracts and 97 say funding doesnt
  cover costs.
• Cancer patients account for 27 of deaths yet
  make up majority of patients receiving specialist
  palliative care and more likely to get active
  case management. Over 70 of PCTs say the group
  with the greatest un-met need are people with
  diagnoses other than cancer.

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High Level Findings

• Coordination of services between health and
  social care is poor and hampered by different
  funding streams
• Lack of progress on national tariff
• Not all carers receive the assessment they are
  entitled to, and respite care is not available in
  all PCTs
• There is a lack of pre-registration training for
  nurses and doctors in end of life care (only 29
  doctors and 18 nurses), but training in the
  national tools (GSF LCP PPC) has improved
  confidence.

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High Level Findings

• The number of non-cancer patients who receive
  specialist palliative care services is increasing
  but remains low
• Potential to improve services within existing
  resources (104 million could be released for
  redistribution)
• Good practice examples show what is and can be
  done (appendix 6 including Marie Curie
  delivering choice project)

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Analysis of Medical Records

• Looked at 348 deaths in Sheffield PCT 52 of
  which occurred in hospital cancer patients had
  the highest proportion of deaths outside hospital
  but still scope to decrease the number of
  cancer patients who died in hospital as there was
  capacity in the local hospices.
• Of all deaths over three quarters were over 65
  years old and a quarter had dementia.
• 40 of people (80 patients) who died in hospital
  had no medical reason to be there at the point of
  admission.

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Analysis of Medical Records

• 40 for whom an alternative was identified were
  in hospital less than 1 week before dying (? not
  identified or care not managed).
• 19/42 who were in hospital for a month or more
  could also have been cared for in an alternative
  setting. (? Discharge arrangements)
• Patients with an alternative spent 1,500 days in
  hospital at a cost of 375,000 (4.5m per year)

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Alternative place of care by condition
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Actual and potential place of death
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Economic Modelling

• Calculated a baseline of current cost of care and
  examined effect of reduced hospital use ( On
  average cancer patients who died in 2006-07 spent
  345 days at home 17 days in hospital and two
  days in a hospice prior to death)
• We estimated that the cost of caring for cancer
  patients in last year of life was 1.81bn)
• Potential to release considerable levels of
  resources while reducing length of time people
  spend in hospital
• 104 million could be released by reducing length
  of stay per admission by 3 days and number of
  admissions by 10 for cancer patients alone (27
  of all deaths)

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Achieving reductions in hospital utilisation

• Reducing admissions requires services to respond
  quickly to needs 24/7 (are a number of service
  models but few 24/7)
• Reducing average LOS requires effective and
  timely discharge arrangements involving multiple
  agencies with appropriate packages of care.

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Feedback from Focus groups
Improvements in equity and consistency of access to services across all disease groups The removal of all mixed sex wards to improve dignity of and respect for patients There should be adequate permanent nursing staff on hospital wards in order to improve continuity of care
Access to high quality respite care should be available to all individuals receiving end of life care services Easy access to counselling for both patients and carers Improvements in the availability of electric wheelchair provision
More information should be made available regarding accessing direct payments There should be one key contact for patients and carers to access information and support regarding their specific needs Improved access to carer assessments
Training, particularly around dignity and respect at end of life, should be made compulsory for all health and social care staff, including GP receptionists Improved information provision, including information packs containing health and social care information, and a mentoring service for patients and carers. Improvements in PCT procedures regarding reviewing access to life-prolonging drug therapies
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Overall Conclusions

• A lack of support means many people die in
  hospital when there is no clinical reason for
  them to be there.
• There is scope to improve training of NHS and
  social care staff, and extend specialist
  palliative care services to all need them,
  whatever their condition.
• More effective partnerships between the NHS,
  social services and the voluntary sector is
  required
• The skills developed in the hospice movement,
  primarily in working with cancer patients, could
  be extended to patients with other terminal
  conditions.
• The Department should support PCTs to reconfigure
  services and to better meet the needs of their
  population

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Further Information

• www.nao.org.uk
• Karen.Taylor_at_nao.gsi.gov.uk or
• Karen.jackson_at_nao.gsi.gov.uk
• 020 7798 7161